PRIVACY ACT MATERIAL REMOVED © GOVERNMENT OF THE MARSHALL ISLANDS Majuro, Marshall Islands Special Health Survey Name - Sex ff Age 3 Residence: 1954-1960 — Cele lafber 1960-1966 — nd 1966-1972 — thee 197 2- Snore — aescription of pA. symptoms: T Nherdbacles Gortey P at Shakes a. L DALE Beetoner | Paw ~~ ler OrCo Affect:i £6Cow | Surgery 7 Year — Have you been receiving treatment for any illness for a perica over xc one year?2? < Has anyone in your family complained of similar symptoms to cne ones you are now experiencing? 5 Surgery? Op. (Son ) Chey. C feel -aLl Ho C12) “4 Signature _ pate Sil mus, 011015 PRIVACY ACT MATERIAL REMOVER